ABM Candid Conversations: A Virtual Interview with Protocol Authors Helen Johnson, MD and Katrina Mitchell, MD IBCLC

ABM is excited to launch the beginning of our Candid Conversations series, featuring ABM members and their various initiatives within the Academy as well as their professional lives. This week, ABM sat down virtually with Helen Johnson, MD and Katrina Mitchell, MD IBCLC, two authors of our most recent protocol Breast Cancer and Breastfeeding, to discuss how they became interested in breastfeeding medicine, what lead them to creating their protocol, and what shifts they’ve seen in practice over the last year with the current health crisis.

Q: Please introduce yourself and provide any background or work information you’d like shared.

HJ: I am a native of Tampa, Florida and a graduate of Brown University’s Program in Liberal Medical Education. I am currently in my fourth year of general surgery residency at East Carolina University/Vidant Medical Center in Greenville, North Carolina. After residency I plan to pursue fellowship training in breast surgical oncology, and am currently working towards IBCLC certification. My goal is to be able to provide high-quality care for patients with any breast condition, whether benign or malignant, and/or occurring during unique periods such as pregnancy or lactation. I am passionate about research and evidence-based medicine, and hope to contribute to the advancement of scientific and medical knowledge related to breast disease.

KM: I’m a breast surgeon and lactation consultant in Santa Barbara, California. My practice focuses on the operative management of breast cancer, but I also care for breastfeeding dyads with a variety of lactation-related questions and concerns.

Q: How did you discover/enter the world of breastfeeding medicine?

HJ: I experienced challenges breastfeeding my children. When I sought medical evaluation for a breast condition, I was shocked by the fragmentation of care. I was able to receive timely, helpful support from a lactation consultant, but it was much more difficult to find a clinician with prescribing privileges who was knowledgeable about lactation. A colleague encouraged me to join the Facebook group Doctor Mothers Interested in Lactation Knowledge (“Dr MILK”), where I learned a great deal about breastfeeding from other physicians. It was through Dr MILK that I first learned about ABM and the field of breastfeeding medicine. I was so pleased to learn that there is a field devoted to breastfeeding medicine including care of the lactating breast, as I want to be able to help any patient with any breast concern.

KM: During my breast surgical oncology fellowship in Houston, Pamela Berens was my breastfeeding medicine physician after the birth of my son. She introduced me to the ABM, and my son and I attended our first conference in Portugal when he was 7 months old.

Q: How has being a member of ABM contributed towards your profession/life?

HJ: Contributing to ABM protocols has been such a rewarding experience. I have gained a deeper appreciation for the strength of the evidence for specific recommendations, and the process of developing societal guidelines. I have especially enjoyed collaborating with other physicians who are passionate about breastfeeding medicine. Through these collaborations, I have cultivated both professional connections and meaningful friendships.

KM: The collaborative multidisciplinary aspect of ABM has opened an entirely new dimension in my professional and personal life. I have developed a much more complex understanding of breast biology and pathophysiology than I ever knew as a breast surgeon alone. I also have learned a great deal about pediatrics and the peripartum care of women, including the mental health challenges many patients experience. I have been so fortunate to have multiple mentors in breastfeeding medicine from different specialties, and I continue to learn something new each day. I feel like I have completed a second residency in breastfeeding medicine!

Q: What lead you to identifying the topic you chose for the Protocol?

HJ: As a surgical resident who plans to practice breast surgery, I have a strong professional interest in the intersection between breast cancer and breastfeeding. Little is taught about lactation in medical school or surgical training, yet breast surgeons and other physicians are entrusted with caring for breastfeeding patients with a current or past history of breast cancer. As a moderator for Dr MILK, I read countless questions from other physicians about breast cancer screening, breast cancer treatment during breastfeeding, and breastfeeding among breast cancer survivors. My impression was that physicians across multiple specialties would benefit from a practical, evidence-based resource to utilize when caring for this unique patient population.

KM: Hyperlactation often results in complications that are surgical in nature – such as plugging, galactoceles, abscesses, and nipple conditions. We thought it would be helpful to outline a standard approach to decreasing milk production in these patients to reduce maternal and infant complications of hyperlactation. At the IABLE Ranch conference in 2019, we drafted this protocol and had great input from colleagues in different specialties who have practiced breastfeeding medicine in a variety of contexts.

The intersection of breastfeeding and breast cancer is a very challenging clinical scenario, and can be difficult for patients psychosocially as well. Because we receive so many questions regarding this topic, we wanted to outline standard, evidence-based guidelines for the care of these patients.

Q: What difficulties has COVID-19 and its side effects (both in medicine and practice) presented to the implementation of your protocol? Or conversely, are there aspects of the current pandemic that have assisted it in any ways?

HJ: In general, there have been many delays in routine cancer screening as a result of COVID-19, and sadly there has been an increase in the proportion of cancers which are advanced at presentation. Many institutions had to halt non-emergent surgeries in order to divert resources towards care for COVID-19 patients, creating the need to utilize neoadjuvant treatment for breast cancers that were otherwise appropriate for up-front surgical therapy.

KM: Both cancer surgery and the care of breastfeeding dyads is not elective, so I have continued to see a large majority of patients in person, using standard precautions. Telemedicine has allowed me to care for patients in other parts of our state, but there are significant limitations to evaluation via telemedicine. The protocols have been very useful to share with colleagues during this time.

Q: In your own life, what ways have you seen the pandemic change your daily working and life routines?

KM: Remote learning is a real challenge for children and families. We are very fortunate that my son meets state of California childcare guidelines for attending transitional kindergarten in person. I am incredibly thankful to his school and teachers for what they do. I’m concerned about the multitude of psychosocial and economic impacts of the shutdown, as well as patients avoiding care for other medical problems not related to Covid.

Q: What are suggestions or tips you may have for physicians trying to implement your protocol, or more generally, support a breastfeeding parent at this time?

HJ: I would remind readers that these protocols are living documents which are updated regularly, and that there remain many areas in breastfeeding medicine with limited evidence. As such, I would encourage cross-disciplinary collaboration with other ABM members when seeking assistance for a challenging case as there may be more recent evidence to consider, and tips to be learned from the experiences of other breastfeeding medicine physicians.

KM: Using standard precautions, I think it’s essential to evaluate patients in person whenever safely possible.

Q: Any additional thoughts?

HJ: I would encourage surgeons who perform breast surgery to utilize ABM protocols and seriously consider joining ABM and learning more about breastfeeding medicine.

KM: Thank you to my ABM colleagues for their mentorship, friendship, and support. Thank you to Helen Johnson for her friendship and incredible work ethic as a researcher and publisher.